Other·October 3, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ***** AMENDED ***** THIS FORM CMS-2567 IS AMENDED TO INCLUDE THE OUTCOME OF THE INVESTIGATION OF COMPLAINT INTAKE NUMBER CA00484619. ALL OTHER ITEMS OF THIS FORM REMAIN UNCHANGED AND EFFECTIVE. The following reflects the findings of the California Department of Public Health during the Recertification survey visit from 4/26/2016 to 5/2/2016. Survey findings included the investigation of one complaint. Complaint Number: CA00484619. One deficiency was issued for Complaint CA00484619. See F309. Representing the Department: Health Facilities Evaluator Nurses: 33833, 36544, 36593 and 36736. The resident census at the start of the survey was 54.

F253 SS=B HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.15(h)(2)

F253 06/06/2016 The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 1 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE failed to provide a clean and comfortable environment. This failure had a potential to affect resident's well-being when exposed to uncomfortable and unsanitary condition. Findings: During an observation on 4/26/16 at 8:10 a.m., there was a very strong musty odor upon entering Room 35. The room had five residents and the floor area around bed C and E was dirty. During an observation on 4/27/16 at 6:35 a.m., Licensed Vocational Nurse (LVN) 2 prepared medications for Resident 19 and brought medications to the resident at her bedside. LVN 2 pulled the cord to turn on the over head light. Once the light was turned on, it started flickering and it continued to flicker until LVN 1 turned it off after giving the medications to Resident 19. During an observation and concurrent interview on 4/26/16 at 3:35 p.m., Director of Maintenance confirmed the ceiling in the social dining room was visibly dirty with clumps of dust on all the fans. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 2 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F257 COMFORTABLE & SAFE TEMPERATURE LEVELS CFR(s): 483.15(h)(6)

F257 06/06/2016

F309 06/06/2016 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 - 81° F This REQUIREMENT is not met as evidenced by: Based on observation and interview for three of 22 residents (Resident 1, 17, and 18), the facility failed to provide an ambient temperature was less than 71° Fahrenheit. This failure had a potential to affect residents' well-being when their environment was not comfortable. Findings: During a confidential group interview on 4/26/16 at 1:10 p.m., Resident 17 and 18 stated the facility gets really cold especially at night time and early in the morning. During an interview on 4/27/16 at 9:35 a.m., Resident 1 stated his room gets cold during night. During an observation and concurrent interview on 4/29/16 at 8:05 a.m., Administrator stated the thermostat was located on the hallway. The thermostat located along hallway closed to nursing station 1 showed 70° Fahrenheit.

F309 PROVIDE CARE/SERVICES FOR HIGHEST SS=H FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 3 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE WELL BEING CFR(s): 483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review for one of 16 sampled residents (Resident 1) the facility failed to implement treatment orders to assess and provide appropriate pain relief based on comprehensive assessment and care plan. Resident 1 was admitted on hospice (Hospice program - supportive care for the end of life with focus on comfort and quality of life) and suffered chronic and acute pain due to prostate cancer, muscle spasm, and repetitive muscle contractions. This failure resulted in Resident 1 experiencing unrelieved pain and unnecessary suffering due to a lack of assessment and appropriate pain management. Findings: Review of Resident 1's Minimum Data Set (MDS- comprehensive assessment tool) dated 4/06/16 showed Resident 1 was admitted to the facility on 3/24/16 with multiple diagnoses that included prostate cancer and painful muscle spasm, and involuntary and repetitive muscle contractions that cause twisting of body parts. "Brief Interview of Mental Status" score of 15 (Resident 1 had an accurate recall of short and long-term memory). Assessment of activities of daily living assistance showed Resident 1 was totally dependent on staff with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 4 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE one person physical assist for moving in bed, dressing, eating, personal hygiene, and bathing. Pain assessment interview showed Resident 1 was "Almost constantly having pain" with pain intensity of 8 from pain scale of 0 - 10. Resident 1 was on hospice program upon admission to the facility (Hospice program - supportive care for end of life with focus on comfort and quality of life). Review of Resident 1's care plan dated 3/25/16 for pain due to prostate cancer and painful muscle spasm indicated "Assess intensity of pain on 1- 10 scale if resident is able. Also assess for quality of pain, e.g., burning, throbbing, aching, dull, or sharp. Pain scale for alert/oriented residents: 1 - 3 = mild pain, 4 - 7 = moderate pain, 8 - 10 severe pain ....Medication per order. "A Hospice care plan dated 3/25/16 showed that "Observe resident for s/s of pain &or discomfort & medicate prn " (s/s - signs and symptoms; prn - as needed). Review of Resident 1's Hospice order dated 3/24/16 showed the following: morphine sulfate 20 milligram/millimeter (mg/ml) to be given 0.25 ml under the tongue every one hour as needed for pain (Morphine Sulfate - narcotic pain medications used to treat moderate to severe pain). Monitor episodes of pain every shift. Monitor episodes of difficulty breathing. Another physician order by Resident 1's admitting doctor dated 3/25/16, for Morphine Sulfate 20 mg/ml, 0.25 ml every hour as needed for shortness of breath or pain. Review of Resident 1's Medication Administration Record (MAR) for the month of March 2016, showed Resident 1 was not assessed for pain on 3/25/16. On 3/26/16 Resident 1 complained of pain twice with a level of 9 and 8. On 3/27/16, Resident 1 was not assessed for pain. On 3/28/16, Resident 1 complained of pain twice with level of 8 on both occasions. On 3/29/16, Resident 9 was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 5 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessed for pain. On 3/30/16, Resident 1 complained of pain level with a 5. On 3/31/16, Resident 1 complained of pain once with level of 8. Resident 1's MAR for the months of March and April did not have pain assessment every shift as ordered. During an interview on 4/27/16 at 9:35 a.m., Resident 1 stated during the first few days he was in the facility he waited a long time for the nurse to get his pain medications. Resident 1 added that while he was waiting he would try to reposition himself just to get some relief. During an observation and interview on 4/28/16 at 1:30 p.m., Resident 1 stated he had pain all the time in his feet and pointed to his right wrist. During an interview and concurrent record review on 4/29/16 at 10:40 a.m., Physician 1 stated it was a problem that Resident 1's pain was not getting assessed on regular basis and his pain was not getting controlled. Physician 1 further stated that it was a concern the morphine sulfate that was ordered and every shift pain assessment was not transcribed on the electronic MAR. During an interview and concurrent record review on 4/28/16 at 3:45 p.m., Hospice Nurse stated Resident 1 had no orders for around the clock pain control medication. Hospice nurse stated the Morphine Sulfate was not the first pain medication the nurse should use. On the MAR for 3/26/16 at 02:07 a.m., Resident 1 had a pain level of 9, Hospice nurse stated Resident 1 received Tylenol with codeine #4 tablet (Tylenol combined with narcotic pain medication) and if the nurse reassess him about three hours later and pain was still present then, the nurse could use the Morphine Sulfate. Hospice Nurse added the nurse should monitor Resident 1's pain level at least every shift. Hospice Nurse stated Resident 1 reported he wished the nurses could get to him faster. Review of Hospice Nurse noted dated 3/29/16 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 6 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE at 10:30 a.m., showed "Pt. states wants to make sure he gets meds on time." During a follow up interview on 4/29/16 at 11:20 a.m., Hospice Nurse stated at a level of 9/10 in the pain scale, it was more appropriate to treat the pain with Morphine Sulfate, since Morphine Sulfate will give Resident 1 a quicker relief from pain. During an interview and record review on 4/29/16 at 7:40 a.m., Director of Nursing (DON) confirmed the Morphine sulfate 20 mg/ml, to be given under the tongue ever hour as needed for pain was not on the MAR, and there was no pain assessment every shift. During an interview and concurrent record review on 4/29/16 at 1:15 p.m., DON reviewed Resident 1's MAR and confirmed the pain scale approved by the facility to use by nursing staff for assessing resident's pain was not listed on the MAR. Review of the facility's policy and procedure titled "Pain Management" dated 09/01/2008 showed, "To assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication .... The licensed nurse shall assess the resident's pain utilizing the pain scale approved by the facility. "The facility's pain scale showed 0/10 - no pain; 4 - 7/10 - moderate pain; 8 9/10 - severe pain; 10/10 -excruciating pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 7 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 06/06/2016

F329 06/06/2016 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to provide a safe environment when the ceiling light fixture in a social dining room was not securely attached to the ceiling. This failure had a potential to cause an avoidable accident or injury Findings: During an observation on 4/26/16 at 3:10 p.m., in the social dining room, one ceiling light fixture's cover was missing and two light bulbs were exposed. The ceiling light fixture was not securely attached to the ceiling. During an observation and concurrent interview on 4/26/16 at 3:35 p.m., Maintenance Director confirmed the ceiling light fixture's cover was missing and it was not securely attached to the ceiling.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l) Each resident's drug regimen must be free FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 8 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to monitor adverse drug reactions related to the use of methadone and morphine (opioid narcotic pain medications used to treat moderate to severe pain) for one (7) of 16 sampled residents when: Resident 7 was not monitored for respiratory depression, a Black Box Warning (the strictest warning put on the labeling of prescription drugs by the food and drug administration when there is a reasonable evidence of an association of a serious hazard with the drug). This failure resulted to Resident 7 becoming unresponsive and was transferred to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 9 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE emergency room where she was treated for narcotic overdose. When she returned from the hospital, the failure to monitor for respiratory depression continued which had the potential for a repeat adverse drug reaction or narcotic overdose. Findings: Review of the admission record, dated 10/2/15, revealed Resident 7 was admitted to the facility on 5/30/13 with diagnoses of chronic pain and asthma (a condition in which a person's lungs become inflamed, and the airways are narrowed, swell, and produce extra mucus, which makes it difficult to breathe). The physician order dated 1/31/16 revealed Resident 7 was getting Methadone 45 milligrams (mg) three times a day for pain. During an interview with Resident 7, on 4/28/16 at 8:15 am, she stated she just returned from the hospital and she had pain in her legs. She stated she could not remember why she was transferred to an acute hospital. Review of the medication administration record (MAR) for the month of March 2016 through 4/13/16 revealed Resident 7 received 45 mg of Methadone three times a day for pain management, and there was no documented evidence of monitoring for side effects of the drug. Review of Resident 7's care plan for pain management initiated 10/22/13 with review date of February 2016 revealed there were no interventions developed to monitor for decreased rate of breathing or any other side effects of methadone. During a review of the record titled SBAR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 10 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Situation Background Assessment Recommendation) communication form and progress notes (a nurses documentation tool used when a resident's condition changes), dated 4/13/16 revealed Resident 7 was unresponsive at 3:40 p.m., 911 was called, and the paramedics arrived and took over care. During a review of the hospital History and Physical and Interim Summary dated 4/13/16, revealed Resident 7 was in the emergency room on 4/13/16, minimally arousable, and treated with Narcan (an antidote used to reverse the effects of narcotic overdose in an emergency situation). Resident 7 was noted to have a low level of oxygen in her blood. And a heart exam revealed she had an abnormally rapid heart rate. The Hospital Discharge Summary dated 4/19/16 revealed the diagnosis of opioid (methadone/narcotic) overdose ...discharged on morphine (opioid/narcotic) which would be safer than methadone. Review of the clinical records indicated Resident 7 was readmitted on 4/19/16 with physician order for long acting morphine (MS Contin) that this is much safer than methadone. Review of physician summary order for the month of April 2016 indicated Resident 7 medication orders dated 4/19/16 included MS Contin tablet extended release 15 mg give 2 tablet by mouth two times a day for pain management and Morphine Sulfate tablet 15 mg give one tablet every 3 hours as needed by mouth two times a day for pain management. During a review of the medication administration record (MAR) for 4/19 /16 to 4/25/16 indicated MS Contin tablet extended release 15 mg give 2 tablets by mouth two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 11 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE times daily for pain management was administered. There was no documented evidence of monitoring for respiratory depression, or other side effects possible with the use of MS Contin. During an interview with Licensed Vocational Nurse (LVN) 3, on 4/28/16 at 10.45 a.m., revealed she could not locate in the MAR where the nurses were monitoring for the side effects of morphine. According to Lexicomp Online, (a drug reference site for professionals) serious, life threatening, or fatal respiratory may occur with use of morphine ER. Monitor for respiratory depression, especially during initiation of morphine ER or following a dose increase.

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.65 06/06/2016 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 12 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow its own infection control policy to help prevent the spread of disease and infection. The facility staff did not wear personal protective equipment (PPE) while performing housekeeping duties. This failure had the potential for the spread of infection and cross contamination. Findings: In an observation on 4/26/16 at 11:15 a.m., the Housekeeper (HK) was observed inside isolation Room 28 mopping the floor and wiping countertops. The HK was not wearing the PPE. There was a precaution sign outside the room that stated to contact the nurse prior to entry and there was a cart by the door with supply of protective clothing and equipment. In an interview on 4/26/16 at 11:25 a.m., the HK stated that he had worked in the facility for fifteen years as a housekeeper. When asked about the facility policy for the isolation room, he stated he was told that he did not have to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 13 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wear PPE for cleaning Room 28 since he did not provide direct patient care. He added that he used an "everyday mop" for everyday mopping of all the rooms including the isolation room. However, he would only wear the PPE in the isolation room when the resident had a "big accident, and bowel movement on the floor or mattress" that needed to be cleaned with "mega mops." In an interview on 4/27/16 at 10:35 a.m., the Director of Nursing (DON) stated that it is the facility policy that everybody entered the isolation room had to wear the PPE including the visitors and housekeeping staff. In an interview on 4/27/16 at 2:05 p.m., the Director of Staff Development (DSD) stated that all staff and visitors were required to wear PPE when they entered the isolation room. In an interview on 5/2/16 at 3:10 p.m., the Administrator stated that: 1. The Administrator is also the Housekeeping Supervisor. 2. Everyone has to follow the facility policy for isolation precaution whether performing direct patient care or other tasks. 3. The facility isolation policy applies to housekeeping, nursing and to all staff and visitors. 4. Employees who are not compliant will be given In-service education on Isolation precaution procedure and maybe disciplined for non-compliance. Review of the facility's policy and procedure titled "Personal Protective Equipment" dated (Sept. 2005), showed that, " Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with our facility's personnel policies." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 14 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F457 BEDROOMS ACCOMMODATE NO MORE THAN 4 RESIDENTS CFR(s): 483.70(d)(1)(i)

F457 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/06/2016 Bedrooms must accommodate no more than four residents. This REQUIREMENT is not met as evidenced by: Based on observation, and interview during the 4/26/16 survey, the facility had six resident rooms that accommodated more than four residents. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: Room 26 5 beds Room 27 6 beds Room 29 6 beds Room 31 6 beds Room 33 6 beds Room 35 5 beds During random observations of care and services from 4/26/16 to 4/29/16, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative attributed to the decreased space and/or safety concerns in the eight rooms. Recommend granting room size waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 15 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F458 BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.70(d)(1)(ii)

F458 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/06/2016 Bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. This REQUIREMENT is not met as evidenced by: Based on observation, and interview during the 4/26/16 survey, the facility had six resident rooms that had bedrooms to measure less than 80 square feet per resident in multiple resident bedrooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: Room Activity Room Size Floor Area 23 Pt Room 235.3 sq.ft. 78.42 sq.ft/bed 25 Pt Room 235.3 sq.ft 78.42 sq.ft/bed 27 Pt Room 465.6 sq.ft. 77.59 sq.ft/bed 29 Pt Room 465.6 sq.ft. 77.59 sq.ft./bed 31 Pt Room 465.6 sq.ft. 77.59 sq.ft/bed 33 Pt. Room 465.6 sq.ft. 77.50 sq. ft./bed During random observations of care and services from 4/26/16 to 4/29/16, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 16 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055715 (X3) DATE SURVEY COMPLETED 05/02/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE space and/or safety concerns in the eight rooms. Recommend granting room size waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NLPT11 Facility ID: CA020000112 If continuation sheet 17 of 17